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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565801505
Report Date: 09/27/2022
Date Signed: 10/31/2022 09:57:47 AM

Document Has Been Signed on 10/31/2022 09:57 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:FAMILYCARE COTTAGE ONEFACILITY NUMBER:
565801505
ADMINISTRATOR:CHRISSY CORTEZFACILITY TYPE:
740
ADDRESS:820 CALLE CEDROTELEPHONE:
(805) 492-1200
CITY:THOUSAND OAKSSTATE: CAZIP CODE:
91360
CAPACITY: 6CENSUS: 6DATE:
09/27/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Chrissy Cortez - AdministratorTIME COMPLETED:
03:45 PM
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At approximately  1:45pm, Licensing Program Analyst (LPA) Brian Balisi arrived at the facility unannounced to conduct a required annual visit. LPA was greeted and screened by staff.  LPA met with Administrator Chrissy Cortez  and explained the reason for the visit. This annual had a specific emphasis on infection control practices and procedures.

LPA toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. Fire extinguishers were observed fully charged and purchased in May 2022.

LPA observed the kitchen/dining area. Knives were observed stored in a locked cabinet above the oven exhaust. Kitchen appliances appeared to be in operable condition. The facility has a sufficient supply of perishable and non-perishable food properly stored.  Medications were observed stored in a locked medication cart located in the kitchen.  First aid kits were observed stored in medication cart.   At 1:50pm, LPA observed (2)  residents watching television in the living room.

All Restrooms were observed relatively clean, sanitary and in operating condition with grab bars and non-skid mats. Hot water measured between 105 - 117 degrees Fahrenheit.

Common Areas: These included the living room and dining area. The common areas were checked for cleanliness and furniture was checked for functionality during time of visit.  There is an attached garage that was observed to be locked and inaccessible to residents in care. LPA observed extra medical equipment, medical supplies, decorations as well as (2) extra fridges with perishable food properly stored. Washer and dryer were located in the garage as well. Each exit way to the outside triggered a notification device.
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Brian Balisi
LICENSING EVALUATOR SIGNATURE: DATE: 09/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/27/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: FAMILYCARE COTTAGE ONE
FACILITY NUMBER: 565801505
VISIT DATE: 09/27/2022
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Continued from 809

LPA observed resident bedrooms, which were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. Inside temperature was maintained at a comfortable level. At 2pm, LPA observed some residents sleeping in their bedrooms.

Surrounding Grounds (Outdoors): There was a shaded outdoor area with multiple pieces of  furniture appropriate  for outdoor use in the rear of the facility.  There are no bodies of water on the premises. LPA observed exit way were  free of obstructions and hazards at this time.

 
The LPA spoke with Chrissy  regarding the facility’s infection control practices. Upon entry, the facility has a central entry point for symptom screening, temperature checks, and sanitation station. The facility has an adequate supply of Personal Protection Equipment (PPE) and the facility is able to obtain additional supplies as needed. The facility’s cleaning protocol is sufficient. Facility has the ability to isolate residents in one of the (4) private rooms, but facility also has the capability to relocate residents who test positive for COVID-19 to (2) other facilities that are located within a mile of this facility.  COVID-19 testing is conducted weekly for residents and staff. The facility’s policies and procedures as it pertains to infection control are adequate at this time.

Exit interview conducted. Report issued and sent via email.
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Brian Balisi
LICENSING EVALUATOR SIGNATURE:

DATE: 09/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/27/2022
LIC809 (FAS) - (06/04)
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